Counteracting the Effect of Stigma on Education for Substance Use Disorders

To build a successful training program, it is necessary to understand the history of addiction treatment in the United States and the conceptual problems in our society and in our medical education system that have helped to perpetuate current inequities in care. Although alcohol consumption (primarily beer, wine, and cider) was an accepted facet of life in colonial America, loss of control and excessive drunkenness were seen as moral failings. Drinking patterns changed dramatically after the American Revolution, with marked increases in the consumption of hard liquor because of the commercialization of grain production and the expanding distillery industry. By 1830, each American on average was consuming 7 gallons of alcohol a year, compared with 2.4 gallons per person today (2).

Benjamin Rush, honored as a founder of the American Psychiatric Association, is also recognized as the founder of the temperance movement. In 1784, he published a pamphlet that clearly identified alcoholism as a disease. Although they were considered radical when published, his writings shaped medical practice for most of the 19th century. Rush endorsed the social and medical benefits of moderate consumption but linked the consumption of hard, distilled spirits with a range of medical conditions and encouraged the provision of appropriate treatment (3). He also described the medical fatalities and criminal behavior associated with excessive consumption. Rush’s concepts likely guided the thinking of physicians after the Civil War, when opioid use disorder was clearly described and named Soldier’s Disease. At the time, it was common medical practice to prescribe morphine to maintain soldiers injured in that war who went on to develop an opioid use disorder. By the end of the 19th century, the temperance movement had evolved into abolitionism regarding alcohol, along with parallel concerns about Chinese immigration and the “evils” of opium abuse. Eventually, the cultural pendulum swung away from the disease model and ultimately led to the adoption of the criminal justice/moral model as official U.S. policy. This was codified into national law in 1914 with the Harrison Act, which outlawed the medical treatment of opioid use disorder, and in 1917 with the Volstead Act, which established alcohol prohibition. Very quickly, organized medicine dropped its opposition to these changes. This ushered in several generations of physicians with no experience or interest in treating substance use disorders. Jails became the de facto treatment facility for most people with alcohol use disorder or opioid use disorder (4).

The national conversation about addiction began to shift after World War II, as Alcoholics Anonymous (AA) grew in influence and reintroduced the concept of alcoholism as a disease. It is significant that the pressure to provide treatment was largely driven by social and political forces outside of organized medicine. To this day, teaching about addiction is minimal in most medical schools and residencies, and trainees often absorb a strong sense of stigma against individuals with substance use disorders that is imbedded in health care institutions and passed on from staff clinicians and senior trainees to junior house staff (5, 6). As a result, not only does the average health care provider lack the technical information and clinical skills needed to effectively treat individuals with a substance use disorder but he or she is also burdened with stigma and fails to see these people as legitimate patients.

For many years, the Accreditation Council for Graduate Medical Education (ACGME)/Review and Recognition Committee for psychiatry had minimal requirements for addiction training. There were no specific requirements for the amount of teaching, the content, or the amount of time for clinical experience. As recently as 2000, only 75% of psychiatry programs required a substance use disorders rotation. Typically, only 56.3% of other medical subspecialties required addiction training. The number of curricular hours ranged from 12 in family medicine to 3 in obstetrics and gynecology and emergency medicine. In psychiatry, the median number of required curricular hours was 8, with a range of 6 to 14 (7). During this period, psychiatry programs typically satisfied the substance use disorders training requirement with a postgraduate year (PGY) I month rotation on a medical detoxification unit that was often run by an internist or addiction medicine specialist. The teaching focused on screening, medical withdrawal treatment, assessment, 12-step counseling interventions, and referral for addiction treatment. Most programs operated with minimal psychiatric input, and residents trained in such settings rarely gained the skills needed for the long-term management of patients with substance use disorders and co-occurring psychiatric disorders. These treatment programs were often free standing and not part of an academic institution. This type of experience tended to reinforce the idea that addiction treatment was a purely medical and AA enterprise, with no clearly defined role for a psychiatrist. This situation began to change in 2001, when the ACGME required that all psychiatry residency training programs include a minimum 1-month full-time-equivalent supervised clinical experience in addiction treatment.

The literature on addiction training in psychiatry is relatively slim. In 2001, a survey on addiction training in 50 general psychiatry residencies was conducted under the joint sponsorship of the American Psychiatric Association (APA) Committee on Training and Education in Addiction Psychiatry and the Education Committee of the American Academy of Addiction Psychiatry. The authors reported that addiction training was conducted in a wide variety of rotations with great diversity in setting and timing, and no general agreement as to a preferred setting. Most residencies provided the equivalent of 2 months full-time training, but in general, there was minimal opportunity for a long-term clinical experience with patients with substance use disorders under the supervision of a qualified addiction supervisor; program directors frequently expressed concern about the limited availability of addiction faculty. Although the survey authors did not directly explore issues related to stigma, they warned about the risk of “therapeutic nihilism” and clearly stressed the critical need to learn “appropriate therapeutic attitudes” as being equivalent in importance to learning general information about addictions and treatment modalities. The authors indicated that this focus on trainee attitudes was not occurring on a routine basis (8).

A comparable survey conducted with the support of the APA Council on Addiction Psychiatry was published in 2012. This survey included responses from 104 program directors. It noted a similar diversity of settings for substance use disorders training, most often involving psychiatry emergency rooms, consult services, and inpatient programs. Only 19% of program directors reported that trainees were paired with supervisors designated to manage substance use disorder cases. Although patients with a substance use disorder were often encountered in outpatient clinics, 68% of the program directors noted that such patients were referred to other settings for treatment. The authors noted their concern that the experience of treating patients with substance use disorders in these settings “may negatively affect the perception of residents, since they are more likely to encounter intractable cases” (9). It was noted that most programs did not provide an opportunity for residents to provide long-term ongoing treatment to patients with substance use disorders (9).

A study published in 2016 reported on 41 general psychiatry residency programs that responded to a survey requesting information regarding whether the program offered buprenorphine waiver training (10, 11). In total, 75.6% of the programs offered waiver training, and 78.1% offered opportunities for their residents to use buprenorphine, under supervision, to treat patients with opioid use disorder. Programs generally reported favorable opinions about buprenorphine treatment and waiver training, but they also reported numerous barriers toward office-based treatment for patients with opioid use disorder and toward incorporating buprenorphine training into the residency curricula, including the lack of addiction faculty and the lack of organizational support. Higher levels of prescribing were reported by programs that required the waiver training than by the programs where waiver training was offered but was optional. The authors of this study noted the modest response rate to the survey (41 of 188 accredited programs) and probable sampling bias, as respondents in programs that were uninterested in opioid use disorder or buprenorphine training were not likely to return the survey (10). A comparable study of recently graduated psychiatrists reported that those who completed waiver training during residency were more likely to report confidence about the effectiveness of office-based buprenorphine treatment than those who did not complete training during residency (11).

The most recent survey was published in 2018 and was conducted by the Addiction Task Force of the American Association of Directors of Psychiatric Residency Training (AADPRT). It focused on gaps and barriers to more effective addiction training in the general adult psychiatry residency. Responses were obtained from 84 of 200 program directors on the AADPRT electronic bulletin board. Although there was great variability of setting and timing for addiction training, the authors noted “in many programs, addiction training takes place on general psychiatry units in which patients with co-occurring disorders are evaluated and treated, and it is unclear the degree to which these cases are supervised by addiction-trained faculty” (12). A total of 41.67% of the program directors indicated that they had a limited number of faculty with the expertise to provide supervision of patients with co-occurring disorders, and 51.18% indicated that they had a limited number of faculty with the time to supervise residents on these cases (12).

This series of reports shows that there has been a gradual increase in the amount of time spent on rotations where general psychiatry residents see patients with co-occurring disorders or patients with opioid use disorder and a shift away from inpatient, detoxification settings to outpatient settings where it is theoretically possible for trainees to have a long-term experience treating patients with substance use disorders. However, consistent reports about the lack of faculty with addiction psychiatry expertise and the adequate time to provided needed clinical supervision suggest that addiction training is far from adequate in the majority of programs. Reports that a majority of outpatient clinics regularly refer patients with substance use disorders to other settings for treatment reinforce the impression that the residents’ training is not adequate (9). Selection bias has likely affected all of these studies, again suggesting that the majority of general psychiatry programs do not graduate residents who are competent in the long-term treatment of patients with substance use disorders. The VA was atypical in its commitment to addiction treatment, and patients with substance use disorders are not excluded from mental health care. However, many VA training programs do not explicitly highlight working with patients with co-occurring disorders.

Our experience in training physicians to obtain the Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine for opioid use disorder exposed the effects of these negative attitudes and minimal addiction training on clinicians and on the U.S. health care system. Expanding access to buprenorphine treatment for opioid use disorder has been a critical element of U.S. efforts to curb the opioid epidemic, yet this medication remains markedly underutilized. A recent Substance Abuse and Mental Health Services Administration survey of 4,225 waivered clinicians showed that 25% have never prescribed the medication; among those prescribing with the 30-patient limit, the mean number of patients was 10.8; and among those with the 100-patient limit, the mean number of current patients was 28.4. Among the factors associated with lower odds of prescribing buprenorphine were: practice in a hospital or health care system; problems with reimbursement; lack of access to behavioral health providers or addiction specialists; lack of confidence in managing patients with opioid use disorder; resistance from practice colleagues and staff; and lack of institutional support. The authors of the survey concluded that clinician education on the treatment of substance use disorders is inadequate, leading to low confidence in clinical skills and a barrier to the expansion of treatment services (13). The failure of 25% of trainees to ever prescribe and the relatively limited number of patients followed by the majority of prescribers suggests the inadequacy of the standard 8-hour buprenorphine training model and ongoing problems related to resistance from colleagues and institutions.

Many of the senior trainers from organizations designated in the Drug Addiction Treatment Act of 2000 (DATA 2000) have concluded that stigma and concerns about management of behavioral problems are more significant barriers for potential prescribers than any pharmacological issues related to buprenorphine prescribing. This has led to debates about the most effective ways to address these deficits in clinician education. From the perspective of a psychiatrist who has been involved in resident training for almost 50 years, I have come to the conclusion that continuing medical education (CME) courses directed to the practicing clinician are unlikely to adequately reverse stigma and the negative clinical attitudes that are engrained in our culture and in our health care institutions.

We now understand stigma as a primal brain function, similar to fight or flight. All mammals have a protective innate biological predisposition to distinguish “Us” from “Them,” an automatic brain reaction that distinguishes individuals who do not resemble those who are familiar to Us. This enhances the safety of the group and leads to fear of the “Other.” This function has been localized as a preferential activation of the amygdala, the brain region that is associated with precognitive reactions of fear, anxiety, and aggression (14). Although feelings of stigma can be easily increased in circumstances in which individuals or groups feel threatened, but it has become apparent that such deeply engrained biologic responses cannot be reversed by a few hours of CME courses.

Fortunately, we have learned that we can modify these responses and attitudes, but it typically takes specific effort and prolonged exposure to new information and experiences. One approach is perspective talking, pretending you are the “Other” and actively verbalizing your grievances and your feelings. This type of exercise builds empathy. Many religious and spiritual traditions have recognized the problem of stigma and have made similar recommendations. Buddhism recommends compassion and suggests you begin by contemplating the difficulties of others and putting yourself in their shoes. Marcus Aurelius recommended that we acquire the habit of attending carefully to what is being said by another and of entering, as far as possible, into the mind of the other. The book of Exodus admonishes, “You shall not wrong a stranger, nor oppress him; for you were [once] strangers in the land of Egypt” (1).

How do we adapt these recommendations to contemporary psychiatric training? None of these recommendations are foreign to standard practice. Collecting a careful, detailed longitudinal patient history is the best place to start. Practicing kind, empathetic, careful, nonjudgmental listening and paying attention to verbal and nonverbal cues—all of this works. Developing a dynamic formulation, writing up a comprehensive medical history, and presenting your observations to the patient and to your peers and supervisors—all of this is an exercise in careful analysis and verbalization. None of this can happen, of course, if the patient is denied entry to treatment or is not assigned to the trainee in a setting that provides the time for full evaluation and requires respectful attention to the patient. Real change, however, requires a long-term relationship. Only then will the trainee get the in-depth understanding that is the foundation of true empathy. Because of the unique, relapsing nature of the addictive disorders, this type of long-term treatment relationship is essential. Only then will the trainee come to understand the fluctuating nature of motivation and the fragility of recovery, even in the most dedicated patients. Respect for the patient and for the powerful grip of his or her illness will grow out of this long-term close relationship. The reward will be the gratification of being part of the recovery process—seeing the patient reclaim his or her potential and self-respect.

The BU/VA training program grew out of a 1-month PGY IV elective in the VA’s outpatient alcohol clinic (Center for Problem Drinking [CPD]). The clinic was always under the leadership of a psychiatrist expert in treating addictions and accepted patients with the full range of co-occurring psychiatric disorders. There was a multidisciplinary staff, with some professional staff members and clinic volunteers who were also in recovery themselves. From the beginning, AA meetings were held on site, organized by a staff member, and open to all.

Over a number of years, the elective grew in length to 3 months and then eventually to 6 months. As interest in the elective grew among trainees, and faculty came to appreciate the clinical value of the experience, the elective morphed into a required PGY III 6-month rotation for all of the BU psychiatry residents. This was not surprising, given the high incidence of alcohol and drug problems in our veteran patient group. The transition to a required rotation was achieved in a relatively easy fashion by restructuring a previously required PGY III longitudinal outpatient general psychiatry rotation (20 hours/week) into a dual-diagnosis clinic. The former CPD merged into this new dual-diagnosis clinic with minimal change in staff or mission. The enhanced training mission required the development of a new seminar series that included between 2 and 3 hours of on-site teaching per week. Over the next several years, the 6-month rotation was extended to the full PGY III year (20 hours/week) and eventually extended with an additional required half day per week for the full PGY IV year for all of the BU psychiatry residents. This permitted a 2-year continuity experience where patients typically began treatment after completing an inpatient medical withdrawal, were seen more frequently during the PGY III year and were gradually transitioned to less frequent visits as they generally achieved stable sobriety during the resident’s PGY IV year.

The residents’ clinical experience was eventually expanded to include patients in the VA’s methadone clinic. In the past decade, patients in office-based buprenorphine treatment were also added to the residents’ caseload. Because almost every patient with a substance use disorder in the Boston VA addiction treatment system typically has two or three co-occurring psychiatric disorders, this type of longitudinal, co-occurring disorders experience did not minimize the residents’ exposure to the full range of psychiatric outpatients and, indeed, made them comfortable managing a very complex and challenging group of patients (15). Equally important, patients with alcohol use disorder and other substance use disorders—including disorders involving methadone, buprenorphine, and XR-naltrexone—came to be seen as routine within the residents’ standard caseload. In fact, the dramatic positive clinical response seen with buprenorphine treatment in many patients with opioid use disorder has led many residents to seek out jobs that specifically included this type of practice.

During the past 2 decades, the VA has become a leader in developing educational models that have incorporated expanded substance use disorders training in the general psychiatry residency. Here at the BU/VA program, we expanded our PGY III/IV-required co-occurring disorders rotation to include focused teaching on cognitive-behavioral treatment (CBT), and we were one of the first programs in the country to develop a treatment model that required all of the residents to follow patients with an opioid use disorder who were being treated with office-based buprenorphine. In our model, the resident acts as the primary treating clinician while faculty and supervisors with the DEA buprenorphine waiver sign the electronic prescription order. The DEA accepted this supervisory model, and it has been duplicated at training programs across the country.

The most important concept in this training approach is to incorporate work with patients with substance use disorders or co-occurring disorders into standard psychiatric practice, standard clinical settings, and standard residency training. The patients are not referred out to a specialized setting where care is provided by addiction specialists. Every psychiatry resident is expected to become competent in the management of these patients—this type of treatment is seen as routine psychiatric care. This simply reflects the reality of contemporary VA clinical care. Among recent combat veterans, those with a diagnosis of a substance use disorder, 82%–93% were also diagnosed with another co-occurring mental health disorder (16). The National Epidemiologic Survey on Alcohol and Related Conditions study also identified a very high frequency of co-occurring mental health disorders in all patients with substance use disorder (17). Research has shown that such integrated care produces superior results compared with programs that ignore co-occurring conditions or those systems that provide parallel treatment services (18, 19). There is no justification for training that does not prepare clinicians to provide care that meets this standard.

Other programs have developed training models built on these concepts. The Baltimore VA developed a successful inpatient consultation/liaison service that effectively incorporated substance use disorders training. Both the Partners (MGH [Massachusetts General Hospital]/McLean Hospital) psychiatry residency and the New York University program pioneered models that incorporated expanded substance use disorders training beginning in the PGY I year that then permitted residents to follow selected patients with co-occurring disorders for extended outpatient treatment (20). Depending on the unique structure and resources available in any given program, the model can be adapted in a wide range of settings. Common factors for successful training include incorporation of addiction treatment into standard psychiatric care settings, opportunities for long-term multidisciplinary clinical care that permits trainees to develop a close clinician–patient relationship, supervision by skilled addiction specialists, access to current standard-of-care treatment options (particularly medications for addiction treatment), and incorporation of expanded substance use disorders didactics.

Here at the BU/VA program, we chose to build our program on available outpatient resources. This seemed ideal, as the majority of our trainees (like most psychiatrists in the United States) have historically opted for careers in outpatient psychiatry. Initially, one addiction psychiatrist supervised the program and coordinated the didactics, although we were fortunate to also have a number of general psychiatrists who were both comfortable working with patients with co-occurring disorders and available to provide resident supervision. Critical support was provided by the BU training director, the chair of the BU Department of Psychiatry, and the VA chief of mental health. An extended didactic program (eventually 83 hours in the PGY III year; see Table 1) (15) was created with support from psychology staff for CBT teaching and seminars on research methodology. Most of the seminars on medications for addiction treatment, motivational interviewing, and harm reduction were conducted by the program director, but resident trainees were also engaged in the teaching. Each resident was assigned three or four topics over the course of the year and was assigned to research the topic, prepare and present a seminar with PowerPoint slides, and identify assigned readings. This model proved highly successful, permitting the presentation of a comprehensive didactic program in a setting where faculty time was limited. The faculty director was fully engaged with designing the curriculum and supervising the seminars but was not burdened with having to prepare multiple presentations each week. On average, for 1 hour each week, there was either a patient interview or a case presentation that engaged the trainee group in diagnostic assessment and treatment planning. Trainees became familiar with the details of a patient’s history and a review of the clinical management challenges presented by the more complicated patients with co-occurring disorders. All of the didactic seminars were open to other trainees in the clinic. These other trainees ranged from medical and nursing students to PharmD, social work, and nurse practitioner trainees; this mix of trainees typically leads to very productive interdisciplinary case management discussions.

This model can be adapted to other primary care training programs. Box 1 suggests how didactic content and learning objectives might be distributed over a 3-year curriculum. Depending on the clinical specialty, the content can be adjusted to coordinate with the usual assigned rotations in each year. It is essential, however, that the curriculum be embedded into the standard clinical rotations for each specific discipline. Some topics, such as CBT, can be dropped if they are not relevant to the specific discipline. Other topics, such as management of co-occurring medical disorders, should be expanded, particularly in the primary medical specialties. Table 1 identifies the general topic areas covered in the BU PGY III model substance use disorders curriculum, along with the assigned number of hours for each topic area. Included in this series are regular patient interviews and case management discussions. As previously mentioned, this type of group interview and case presentation and discussion not only improves clinical competence but also increases empathy for the patient and is a critical element in the modification of stigma.

Whenever possible, clinicians should be assigned patients with substance use disorders in a multidisciplinary continuity clinic setting and provided ongoing supervision by faculty with expertise in treating the addictions. A longitudinal clinical experience is required for trainees to gain a full appreciation for the gradual process of addiction recovery, including episodes of relapse. Opportunities should be available to work with multidisciplinary treatment teams and to follow patients with AUD and opioid use disorder who are being treated with medications for addiction treatment. Work with patients with opioid use disorder who are being treated with buprenorphine (or XR-naltrexone) is particularly important for physicians, advanced-practice nursing trainees, and physician assistant trainees, as they will eventually be able to prescribe these medications, which are currently underutilized, are highly effective clinically, and can be easily provided within a standard practice setting.

Faculty need to appreciate the pervasive nature of stigma within our culture, even among clinicians, and the frequent failure of standard didactic approaches to reverse ingrained stigma against patients with substance use disorders. Longitudinal clinical experiences provide the opportunity to know and respect patients with substance use disorders as individuals struggling with serious chronic illness and to learn that many can achieve recovery with available treatments. This type of clinical experience is perhaps the most essential element of an effective training program.